Healthcare Provider Details

I. General information

NPI: 1619245404
Provider Name (Legal Business Name): PLUM STREET PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2011
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 PLUM ST
CARMI IL
62821-1632
US

IV. Provider business mailing address

311 PLUM ST
CARMI IL
62821-1632
US

V. Phone/Fax

Practice location:
  • Phone: 618-382-8400
  • Fax: 618-382-5700
Mailing address:
  • Phone: 618-382-8400
  • Fax: 618-382-5700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054.017833
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DON GEE
Title or Position: PHARMACIST/OWNER
Credential:
Phone: 618-382-8330